Health Maintenance Organizations Wake Up… Telemedicine Is the way to go.

INTRODUCTION:

The Nigerian Healthcare system is in a ‘fix’, almost at a near standstill. The different facets of the healthcare system is bridled by one form of problem or another. Well, this write-up is simply to identify one key area that seem to have defiled all efforts aimed at a lasting solution. Indeed, it has lingered for close to a decade… It is the Universal Health Coverage, as regulated by the National Health Insurance Scheme, NHIS.

Many Nigerians still believe this concept, the Universal Health Coverage, is one of those government policies that only improve the lives of a selected few, those within or close to the government. The average person do not know that this is a term, as espoused by the World Health Organization, that assures all peoples of the world that health is a fundamental human right…(WHO Constitution 1948) and that Healthcare is for All…(Alma Ata Declaration 1978)

Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

This definition of UHC embodies three related objectives:

  1. Equity in access to health services – everyone who needs services should get them, not only those who can pay for them;
  2. The quality of health services should be good enough to improve the health of those receiving services; and
  3. People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.

It is my belief that Nigerian Government, in a bid to ‘do the right thing’, have tried to domesticate the fundamentals of the Universal Health Coverage. Hence, the setting up of a system that would meet the objectives of the UHC.

It is over a decade since the establishment of National Health Insurance Scheme, NHIS, but it has failed woefully with respect to providing easy access to healthcare for all Nigerians at an affordable cost through various prepayment systems.

The leadership of the NHIS is rather heaping the buck at the door step of the Health Maintenance Organizations, HMOs, claiming that the HMOs are not doing enough to get more citizens to join the scheme. HMOs disagrees with the NHIS and are blaming the NHIS for not living up to her regulatory role.

The in-fighting has been going on for a while and this may have blinded practitioners on both sides, from looking out for solutions that would stand the test of time.

Telemedicine is still so new in the country with very promising prospects that may just be the missing link to our universal health coverage quagmire.

NIGERIA’S HMOs: STATUS AND CHALLENGES

The NHIS in Nigeria is designed to be driven through the operations of HMOs (which either be private or public companies; or could be either profit or not-for-profit registered entities), with the aim of ensuring the provision of qualitative and cost-effective healthcare services.

HMOs’ STATUS:

Health Maintenance Organizations are set up to deliver quality healthcare to a designated population in a cost effective manner through healthcare providers, who are paid a fixed budget or discounted fee.

HMOs usually have an exclusive network of service providers. Clients under any HMO will not usually pay any part of their bills if they choose a provider outside of the HMOs’ network without prior authorization.

Basically, it is clear that the role of a HMO are;

  1. To register employers/employees
  2. To collect contributions of the above
  3. To register providers, after ensuring they meet minimum NHIS standards.

Another submission of this work is that, one can predict the operational principles of HMOs by what payment system/model they adopt. The payment systems/models include;

  1. Re-imbursement System: Payment are done only after service has been rendered. It is to encourage providers to be more cost conscious
  2. Network or IPA model: The HMO may contract directly with physicians in the community, or may contract with a network of physicians
  3. Group or Staff Model: HMOs have their own physicians on salary or in an exclusive contractual agreement.

CHALLENGES:

 To get first hand the current issues plaguing HMOs, I had to reach to a few former and currently serving HMO officials. It was revealing and enlightening. Health Maintenance Organizations in Nigeria face peculiar challenges, that may have not been reported in other climes.

After due consultation with industry practitioners, and many of them asking not to print their identity, I was able to identify some key points/challenges patients face in the hands of HMOs. These recurring points have been identified as major set backs bedeviling the health insurance sector.

In the eye of some patients/clients, HMOs render services that plagued with a lot of inconvenience and stress.

Practitioners generally agree that the HMOs are simply not doing enough.

For the government, ie the NHIS, HMOs are unrepentant swindlers that receive tax payers monies without doing much more to make sure more Nigerians get covered under the scheme.

Patients experience these challenges;

  • Limitation of Specialist choice and visit time
  • Forceful use of generic drugs rather than branded drugs
  • Problems of Referrals
  • Lack of Attention by hospitals
  • Delayed attention in hospitals

The challenges above are not exhaustive but are simply the most pressing and the commonest. Hopefully in the next segment, I would explore why the challenges/problems above should not be a problem, when Telemedicine becomes an option.

TELEMEDICINE OPTION:

Telemedicine is the use of telecommunication and information technology to provide clinical healthcare from a distance – Wikipedia

Statistically, evidence shows that internet penetration in Nigeria looks positive, with more Nigerians taking to using of telecommunication and infomation technology devices and tools. It is on this basis that Nigeria appears so reap for the telemedicine option.

The California Telehealth Resource Center defines Telehealth as a collection of means or methods for enhancing healthcare, public health and health education with delivery and support using telecommunication technology.

HMOs should begin to take advantage of this new option by engaging credible Telemedicine companies in Nigeria, who are professionals and are equally determined to seal Nigeria’s status as a Health for All compliant nation.

For the purpose of this article I would explore ‘Limitation of specialists’, by the HMOs.

LIMITATION OF SPECIALISTS:

Read this typical story:

Mrs X is a 49year old mid-level bank executive, who has a chronic knee pain and has been managed since she was 45years by a Rheumatologist B. A memo was recently released by her bank informing all workers that a new Health Maintenance Organization, HMO ‘B’, is now for all workers. Mrs X soon discovers that her favorite Rheumatologist B is not on the HMO’s accredited healthcare providers.

Currently she is in pains, because she had to make a trip to the gate keeper’s clinic. who now has to determine which doctor is suited for her. She reminds the gatekeeper that she has a very Rheumatologist, whom she knows is very competent.

The gatekeeper retorts that Rheumatologist B is not on their list of affiliated specialist, and that she has to see an orthopaedic surgeon, since their own Rheumatologist is out of town. Moreover orthopaedic surgery is so similar to Rheumatology.

Now, Mrs X is still in severe pains, and she has got to make up her mind about going to see an orthopaedic surgery specialist, and not a rheumatologist (the most appropriate specialist for her). Or she could simply call up Rheumatologist B and pay out of her pocket to get better.

But what of if HMO ‘B’ has TELEMEDICINE AS AN OPTION; this is what happens:

Mrs X begins to feel the pain, and she immediately place a video call to her gate keeper, who is able to make some remote assessment of the swollen knee. He goes on to send his initial assessment to all the necessary specialist in their network.

He immediately recommends that she goes to see the closest and the most available specialist to begin treatment.

Continuous follow-up, over the next couple of minutes or hours is ensured.

The HMO with Telemedicine as an option offers patients;

  • Convenient and accessible care
  • Saves healthcare cost (like limiting unnecessary ER/hospital visits, makes a typical doctor visit more efficient.
  • Extends and loops in more consults from specialists
  • Increases patient engagement
  • An overall better quality patient care.

It is also recommended that HMOs must adapt a unique, individualistic telemedicine model for her healthcare providers, taking in to account the specialty and frequency of patient visits.

HMOs could begin to source out professional telemedicine companies whom they can work with to help patients get better care, and in the long run, get more people to be under UCH.

Telemedicine companies should begin to fashion out tools that is specialty specific…  Telemedicine companies should decide to focus on one or more key areas as in Teleradiology, Telepsychiatry, Teledermatology, Teleopththalmology, Telenephrology,Teleobstetrics, Teleoncology etc

CONCLUSION

Since in the early 1970s when pioneers of  Health Maintenance Organization coined the concept, it has since evolved to a science. It have since ensured that people get Universal Health Coverage, especially in developed world. The system grew and now grind-on like clock work. The key stalkholders  in the system were the patients, the healthcare providers, the HMOs, the insurance companies, the payers (employers) and government (as regulator).

But this grouping is set to soon add on a new member… TELEMEDICINE COMPANIES.

Telemedicine is a relatively newer concept but have found relevance in our world today. It requires “techincal professionalism” because of its fluid-like nature.

Already it shines as a beacon for all to see. HMOs who foray into Telemedicine as an option will soon stand out from her peers.

Evidence abounds.

Universal Health Coverage and Health for All should be evident in Nigeria!!!

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The Admin is a Medical and Dental Council of Nigeria Certified Medical Doctor. He is popular for being a fast rising online voice in Nigeria, with a flair for animated writing. He is a professional health content writer.
He loves to swim, read and play board games. He see himself as one who is destined to play a role in the way health services are rendered to the human race.

2 Comments

  1. Telemedicine is a good alternative to this epileptic healthcare services in Nigeria. The only issue I have with it is that the Drs will not allow it to see the light of the day.
    Doctors are supposed to be the solution to the healthcare challenges in Nigeria, but they constitute more problems with their egoistic nature. They want to dorminate all aspect of health forgetting that a tree doesn’t make a forest. God help Nigeria health system

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